Epidemiology of Ageing

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EPIDEMIOLOGY OF AGEING
Prepared By:
Dr Zulfiquer Ahmed Amin
M Phil (HHM), MPH (HM), PGD (Health Economics), MBBS
ARMED FORCES MEDICAL INSTITUTE (AFMI)

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EPIDEMIOLOGY OF AGEING
Definition of ageing
1. When talking about ageing, it is essential to distinguish between population or
demographic ageing as “the process whereby older individuals become a proportionately larger
share of the total population” and individual ageing, the process of individuals growing older.
This individual process of ageing is multidimensional and involves physical, psychological and
social changes. The term ‘ageing’ is used to mean the biological changes that occur over time in
an individual that are associated with a gradual decline in function and an increasing risk of
death in the near future.
2. The United Nations uses 60 years to refer to older people. This line, which divides
younger and older cohorts of a population, is also used by demographers. However, in many
developed countries, the age of 65 is used as a reference point for older persons as this is often
the age at which persons become eligible for old-age social security benefits. So, there is no
exact definition of “old” as this concept has different meanings in different societies. Defining
“old” is further challenged by the changing average lifespan of human beings. Around 1900 AD,
average life expectancy was between 45 and 50 years in the developed countries of that time.
Now, life expectancy in developed countries reaches 80 years. There are other definitions of
“old” that go beyond chronological age. Old age as a social construct is often associated with a
change of social roles and activities, for example, becoming a grandparent or a pensioner. Older
persons often define old age as a stage at which functional, mental and physical capacity is
declining and people are more prone to disease or disabilities.
Introduction
3. In 1950, there were 205 million persons aged 60 or over in the world.1 By 2012, the
number of older persons had increased to almost 810 million. It is projected to more than
double by 2050, reaching 2 billion. Currently there are 15 countries with more than 10 million
older persons, seven of these being developing countries. By 2050, 33 countries are expected to
have 10 million people aged 60 or over, including five countries with more than 50 million
older people. Out of these 33 countries, 22 are currently classified as developing countries. The
population aged 60 or over is growing at a faster rate than the total population in almost all
world regions, representing 16 percent of the world’s population. Although more developed
countries have the oldest population profiles, the vast majority of older people—and the most
rapidly aging populations—are in less developed countries. Between 2010 and 2050, the number of
older peopleinlessdevelopedcountriesisprojectedto increasemorethan250percent,comparedwith a
71 percent increase in developed countries. .
4. The world is on the brink of a demographic milestone. The world is facing a situation
without precedent: We soon will have more older people than children and more people at
extreme old age than ever before. As both the proportion of older people and the length of life
increase throughout the world, key questions arise: Will population aging be accompanied by

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a longer period of good health, a sustained sense of well-being, and extended periods of social
engagement and productivity, or will it be associated with more illness, disability, and
dependency? How will aging affect health care and social costs? Are these futures inevitable,
or can we act to establish a physical and social infrastructure that might foster better health
and wellbeing in older age? How will population aging play out differently for low-income
countries that will age faster than their counterparts have, but before they become
industrialized and wealthy?
5. The potential for an active, healthy old age is tempered by one of the most
daunting and potentially costly consequences of ever-longer life expectancies: the
increase in people with dementia, especially Alzheimer’s disease. Most dementia
patients eventually need constant care and help with the most basic activities of daily
living, creating a heavy economic and social burden. Prevalence of dementia rises
sharply with age. An estimated 25-30 percent of people aged 85 or older have
dementia. Unless new and more effective interventions are found to treat or prevent
Alzheimer’s disease, prevalence is expected to rise dramatically with the aging of the
population worldwide. Aging is taking place alongside other broad social trends that
will affect the lives of older people. Economies are globalizing, people are more likely
to live in cities, and technology is evolving rapidly. Demographic and family changes
mean there will be fewer older people with families to care for them. People today have
fewer children, are less likely to be married, and are less likely to live with older
generations. With declining support from families, society will need better information
and tools to ensure the well-being of the world’s growing number of older citizens.

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6. This remarkable phenomenon is being driven bydeclines in fertility and improvementsin
longevity. With fewer children entering the population and people living longer, older
people are making up an increasing share of the total population. In more developed countries,
fertility fell below the replacement rate of two live births per woman by the 1970s, down from
nearly three children per woman around 1950. Evenmore crucialfor population aging,fertility fell
with surprising speed in many less developed countries from an average of six children in 1950
to an average of two or three children in 2005. In 2006, fertility was at or below the two-child
replacement level in 44 less developed countries. Many less developed nations will need new
policiesthatensurethefinancial security of older people, andthat providethe health and socialcare
they need, without the same extended period of economic growth experienced byagingsocieties
intheWest. Inotherwords,somecountriesmaygrowold before they grow rich.
7. In some countries, the sheer number of people entering older ages will challenge national
infrastructures, particularly health systems. This numeric surge in older people is dramatically illustrated in
the world’s two most populous countries: China and India (Figure below). China’s older population –
those over age 65 – will likely swell to 330 million by 2050 from 110 million today. India’s current older
population of 60 million is projected to exceed 227 million in 2050, an increase of nearly 280 percent
from today. By the middle of this century, there could be 100 million Chinese over the age of 80. This
is an amazing achievement considering that there were fewer than 14 million people this age on the
entire planet just a century ago.

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8. Although the growth illustrated by these demographic trends is significant, it has been
relatively slow compared with the increases projected to occur in the next 30 to 50 years (Centers
for Disease Control [CDC] & The Merck Company Foundation [Merck], 2007). In 2000, the
population aged 65 and older was approximately 35 million (12% of the total). By 2030, this
older cohort’s size is expected to double and will represent roughly 20% of the total
population—or one in every five people (Marshall & Altpeter, 2005). The CDC has forecasted
that the increase in older citizens will begin to soar as the baby boomers enter this age bracket
(CDC & Merck, 2007). By 2050, the number of baby boomers aged 85 years and older is
expected to rise to roughly 21 million (Federal Interagency Forum, 2008). These projected
increases in life expectancy can be attributed to improved medical care and an emphasis on
disease prevention measures over the last century (CDC & Merck, 2007).

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State of Science: The Biology of Ageing
9. The study of the biology of ageing is one of the most challenging areas of biomedical
research. A number of general points on this aspect were made by the experts. There were three
main theories about why ageing happens: mutation accumulation; antagonistic pleiotropy; and
the disposable soma theory. These are not mutually exclusive theories, but differ in the
perspectives of their analysis. These three theories all assume that ageing is a natural
consequence of changes that occur over time. A fourth theory, that ageing is a genetically
programmed process that results in a metabolic “clock” turning off at a particular time,
regardless of cell or DNA damage, was not put forward by the experts.
Mutation accumulation
10. There is no doubt from the work with animal models that ageing can be affected by
changes to DNA. Such changes arise naturally in the majority of species, including man, as
mutations. Germline mutations arise in the eggs and sperm. If the resulting variant is
advantageous and operates before or during the reproductive phase, it will spread rapidly through
the population by natural selection. If it is disadvantageous and operates prior to the reproductive
phase, it will be selected against. If the mutations are disadvantageous but only operate in later
life after the reproductive phase, then natural selection cannot act to eliminate them and these
may gradually accumulate in the population. If some of these mutations affect the ability to
maintain and repair cells and tissues, then the cumulative effect would be ageing. These
alterations in DNA over a lifetime represent mutation accumulation. Mutations also occur in
cells other than eggs and sperm. These ‘somatic’ mutations can occur throughout life and may
also contribute to the ageing process.
Antagonistic pleiotropy
11. Antagonistic meaning contradictory, and pleiotropy meaning having two or more
unrelated effects is a refinement of the mutation accumulation theory. There may be some
mutations that give an individual a survival advantage during their reproductive years, but can
cause problems in post-reproductive life, either because of the way in which they work, or
because of unrelated effects. Natural Selection theory would suggest that these genes would
flourish in a population, as they are passed on to many descendants. However, in older age, they
may speed up ageing and decrease lifespan.
Disposable Soma Theory
12. Increasingly, evidence suggests that the complexity of ageing can be better understood by
investigating the way in which multiple individual mechanisms interact and depend on each
other. This has led to the development of models such as Kirkwood’s Disposable Soma Theory.
In this theory, ageing is caused by the combination of accumulated mutations in the DNA,
leading to the formation of faulty proteins and malfunctioning cells, with additional damage
caused by free radicals. The biological investment that is required to repair this damage comes at

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a high energy cost. During reproductive years, natural selection will favour the maintenance of
these repair mechanisms, which keep cells and their DNA working well. However, in older
years, there is no advantage from natural selection to investing in complex repair mechanisms to
prevent the slow accumulation of minor mutations. The older body (or “soma”), in Nature’s
eyes, is disposable.
Mechanisms of Ageing
13. The experts agreed that ageing was most likely to be caused by a complex combination of
intrinsic factors that are specific to the individual, such as their genetic make-up, and extrinsic
factors, such as exposure to environmental agents. However, the experts had different views on
which of these factors were likely to be the most important in the ageing process in humans.
Ageing can be thought of as arising from an intrinsic process characterised by a failure of repair
and maintenance of tissues and organs with increasing age, which overlaps with the
accumulation of age-related diseases such as ischaemic heart disease, stroke and cancers with the
passage of time.
Cell turnover and senescence
14. Cell division is an essential function that leads to growth and development of the
different organs, replaces damaged cells and allows the body to adapt to change. However, it has
to be carefully regulated so that there are enough functioning cells in each organ to keep the
body healthy, but cell division only occurs when necessary, to minimise energy requirements.
Many billions of cell divisions occur in a lifetime, and despite there being many maintenance,
repair, and quality control systems, errors still occur through random events. Many errors have
no material effect on the functioning of a cell and are harmless. Some are harmless until they are
combined with other mutations that give rise to some dysfunction. The accumulation of somatic
mutations is an important part of the mechanism for the development of cancer. In addition to
random error, intrinsic factors in an individual may make the accumulation of a harmful
combination of mutations more likely, such as germline mutations that are inherited and
contribute to the development of disease. Extrinsic factors such as exposure to cigarette smoke
may increase the rate of mutation and hence contribute to the development of cancer or other
diseases. One mechanism that might limit the potential threat of such damage is cell senescence.
Senescence
15. Cell senescence is a process that allows cells to stay alive but no longer able to divide.
Cells that cannot divide do not develop into cancer, and do not consume the substantial energy
stores that are needed each time the cell divides. Cell cultures grown in the laboratory have been
shown to become senescent over time, and there is evidence that this phenomenon also happens
in the body, although research on the topic has been limited by technical difficulties in
identifying senescent cells. Senescent cells can cause problems beyond just taking up space that
could be used by better-functioning cells. The experts we spoke to for this paper have conducted
research on senescence in a number of types of cells including fibroblasts, which provide a

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functional scaffolding in connective tissues and bone. Senescent fibroblasts have been shown to
release chemicals called cytokines that signal to the immune system that something is going
wrong. The immune system response to such a trigger involves the development of
inflammation, and the healing process can result in unwanted effects:
16. Other research has investigated senescence in astrocytes, which are star-shaped cells that
support and help to nourish nerve cells in the brain and spinal cord that serve a similar function
to fibroblasts in the rest of the body. These cells are very sensitive to low oxygen levels, and can
respond to this sort of oxidative stress by becoming senescent.
Figure: Cell senescence occurs after a relatively fixed number of cell divisions. Repair of healthy
tissues demands a plentiful supply of new differentiated tissue cells to replace those that are
injured or diseased. Once cell division ceases, the cells become ‘senescent’, producing
inflammation-mediating chemicals that lead to damage to the cells and eventually cell death, a
process associated with ageing.
Telomere shortening
17. Telomeres are the strands of DNA that make up the ends of chromosomes. Because of the
way in which DNA is replicated, the length of the telomeres shortens each time the cell divides.
Consequently, the length of telomeres in the cells of older people tends to be shorter than in
younger people. It is thought that, once the telomeres reach a certain minimum size, they can
cause the cell to become senescent. In humans, cells can divide approximately fifty times before
cell division ceases, presumably as a result of the exhaustion of the telomeres. This is referred to

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as the ‘Hayflick limit’ after the scientist who first observed it. Telomere shortening has therefore
been identified as a factor that could contribute to ageing. However, the relationship is not a
simple one, and, although short telomeres are associated with the early onset of age-related
disease and death, they are not a good predictor of how long an individual will live or how
healthy they will be before they die. The experts' view was that telomere shortening may
contribute to ageing, but is clearly not the whole story, and that research into this is still at an
early stage.
Figure: Telomeres are DNA caps that sit on the ends of chromosomes. Each time a cell divides,
some of this chromosome cap fails to replicate and is lost to subsequent generations of the cell.
Once the telomere is completely depleted the chromosome ceases dividing.
Oxidative stress
18. Oxidative stress or damage relates to the production of “free radicals” as part of the
body’s metabolism, which can cause random molecular damage and add to the ‘wear and tear’ of
cells over time. It has been suggested that oxidative damage is part of the ageing process. The
body normally combats oxidative damage using anti-oxidants in the diet, such as vitamins C and
E or other chemicals such as resveratrol, which can reduce the long-term damage. As we get
older these defence mechanisms become less effective, not all the damage is repaired, and signs
of ageing develop.

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Nutrient sensing
19. Research on nutrient sensing mechanisms (such as how a cell decides to deal with
glucose) was considered to hold some promise in understanding and potentially influencing the
ageing process. Cell turnover (replacing damaged or malfunctioning cells with healthy new ones)
is linked to nutrient sensing: if nutrients are restricted, the body’s ability to make new cells is
reduced. One of the key mechanisms involved in nutrient sensing is the ‘mechanistic target of
rapamycin’ (m-TOR) pathway. M-TOR is a protein that takes part in the passing of signals from
growth hormones such as somatotropin and the insulin-like growth factors (IGF) to those parts of
the cell that are involved in protein synthesis. It developed in very primitive organisms to control
cell division when there were favourable environmental conditions, and, as animals became more
complex, its function is thought to have evolved into the central co-ordination of growth and
metabolic stability.
20. When there is abundant food available, m-TOR stimulates cell division and growth of the
body. It is also involved in helping the insulin hormone control blood sugar levels.
Overstimulation of m-TOR by excessive food consumption may play a part in the development
of diabetes, and a lack of regulation of the pathway stimulates the uncontrolled growth of
cancers. Dietary restriction deactivates the mTOR pathway, which may slow ageing and delay
the onset of age-related diseases. It is thought that a number of potential anti-ageing
interventions, such as calorie restriction, resveratrol and rapamycin, might work by blocking the
m-TOR pathway.
Changing demography due to ageing population
The relationship between ageing and disease
21. One key issue raised by the experts is the difference between lifespan, or how long an
individual lives, and healthspan, or how long they live in good health. Experts were of the view
that the ultimate goal of ageing research is to increase healthspan, and that delaying ageing might
be a welcome consequence of this process. However, they were mindful that any success in
delaying ageing would not necessarily mean that the period of ill-health before death would be
shortened. Attempts to draw a distinction between an intrinsic ageing process and age-related
disease have been unsatisfactory.

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Insulin-like-growth-factors are produced in response to a high calorie intake. Receptors in the
cell surface transmit this signal to the complex biochemical process controlling metabolism in
the cell (AKT pathway). In response, cell turnover is increased, both directly and via the cell
replication controlling pathway that includes ‘m-TOR’ the mechanistic target of rapamycin. This
pathway controls construction within the cell and can be inhibited by rapamycin. Typically,
differentiated cells can only divide about 50 times before the telomeres are exhausted and the
cell enters a dormant or ‘senescent’ phase. As the cell divides it can be vulnerable to damage
(somatic mutation), and oxidising ‘free radicals’ increase this risk. Accumulations of somatic
mutations affect cell function and can also trigger cancer transformation. The senescent cells
secrete chemicals (cytokines) that provoke inflammation in the surrounding tissues. The
inflammation can damage and disrupt the tissues and their functioning, leading to many of the
features of ageing. Inflammation increases cell turnover and can also increase the risk of cancer.
P53 suppresses cancer by enhancing the repair of accumulated damage to DNA, but also
causes cells to self-destruct (apoptosis). Exercise, low calorie diets and resveratrol increase
activity of sirtuins such as SIRT1, which switches off AKT induced cell turnover and stimulates
‘autophagy’, which destroys redundant or unessential components of the cell, maximising its
efficiency. Statins have an anti-inflammatory effect in addition to lowering cholesterol. They
may also increase telomere repair and inhibit the proliferation of cells inside blood vessels that
contributes to the formation of atheromatous cardiovascular diseases (clogged up arteries).
This outline has been greatly simplified, but even so it begins to convey the considerable
complexity of the network of inter-related processes involved in ageing, most of which remain
poorly understood.
Figure: A simplified representation of the key processes involved in ageing with their
relationships and potential anti-ageing interventions.
New Disease Pattern
22. The transition from high to low mortality and fertility that accompanied socioeconomic
development has also meant a shift in the leading causes of disease and death. Demographers and
epidemiologists describe this shift as part of an “epidemiologic transition” characterized by the
waning of infectious and acute diseases and the emerging importance of chronic and degenerative
diseases. High death rates from infectious diseases are commonly associated with the poverty,
poor diets, and limited infrastructure found in developing countries. Although many developing
countries still experience high child mortality from infectious and parasitic diseases, one of major
epidemiologic trends of the current century is the rise of chronic and degenerative diseases in
countriesthroughouttheworld— regardlessofincomelevel.
23. Evidence from the multicountry Global Burden of Disease project and other international
epidemiologic research shows that health problems associated with wealthy and aged
populations affect a wide and expanding swath of world population. Over the next 10 to 15years, people
in every world region will suffer more death and disability from such noncommunicable diseases as
heart disease, cancer, and diabetes than from the infectious and parasitic diseases. The myth that
noncommunicable diseases affect mainly affluent and aged populations was dispelled by the project,
which combines information about mortality and morbidity from every world region to assess the total
health burden from specific diseases. The burdenis measured by estimatingthe loss of healthyyearsof

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life due to a specific cause based on detailed epidemiological information. In 2008, noncommunicable
diseases accounted for an estimated 86 percent of the burden of disease in high-income countries, 65
percent inmiddle-income countries,andasurprising37percentinlow-income countries.
24. By 2030, noncommunicable diseases are projected to account for more than one-half of the
disease burden in low-income countries and more than three-fourths in middle-income countries.
Infectious and parasitic diseases will account for 30 percent and 10 percent, respectively, in low- and
middle-income countries (Figure below). Among the 60-and-over population, noncommunicable diseases
alreadyaccount formore than 87 percent of the burden in low-, middle-, and high-incomecountries. But
the continuing health threats from communicable diseases for older people cannot be dismissed,
either. Older people already suffering from one chronic or infectious disease are especially vulnerable to
additional infectious diseases. For example, type 2 diabetes and tuberculosis are well- known “comorbid
riskfactors”thathaveserious health consequences for older people.
Rising Disability Trend
25. Are we living healthier as well as longer lives, or are our additional years spent in poor health?
There is considerable debate about this question among researchers, and the answers have broad
implications for the growing number of older people around the world. One way to examine the
question is to look at changes in rates of disability, one measure of health and function. Some
researchers think there will be a decrease in the prevalence of disability as life expectancy increases,
termed a “compression of morbidity.” Others see an “expansion of morbidity”—an increase in the
prevalenceof disabilityaslife expectancyincreases.

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DISEASE STATUS
26. An important aspect of disease status that distinguishes the older population from the
younger population is the high rate of co-occurrence of multiple chronic conditions, termed
comorbidity. The concept of comorbidity is useful in considering the burden of disease in older
people; however, the standardization of a definition for comorbidity depends on the number of
conditions being ascertained and the intensity of the diagnostic effort to identify prevalent
diseases. The longer the list of conditions and the harder one works to find prevalent diseases,
the greater the prevalence of comorbidity.

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The Burden of Dementia
27. The cause of most dementia is unknown, but the final stages of this disease usually means a loss of
memory, reasoning, speech, and other cognitive functions. The risk of dementia increases sharply with age
and, unless new strategies for prevention and management are developed, this syndrome is expected to place
growing demands on health and long-term care providers as the world’s population ages. Dementia
prevalence estimates vary considerably internationally, in part because diagnoses and reporting systems
are not standardized. The disease is not easy to diagnose, especially in its early stages. The memory
problems, misunderstandings, and behavior common in the early and intermediate stages are often

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attributedto normaleffectsof aging, acceptedas personalitytraits,or simplyignored. Many cases remain
undiagnosed even in the intermediate, more serious stages.
28. Alzheimer’sdisease(AD)isthemostcommon form of dementia and accounted for between two-
fifths and four-fifths of all dementia cases cited in the OrganizationforEconomicCooperationanddevelopment(OECD)
report. More recent analyses have estimated the worldwide number of people living with AD/dementia at
between27 million and36 million.Theprevalenceof ADandother dementiasisverylowatyoungerages,
then nearly doubles with every five years of age after age 65. In the OECD review, for example, dementia
affectedfewerthan3percentof thoseaged65to 69,butalmost30percentof thoseaged85to89. Morethan
one-halfofwomenaged90orolder haddementiainFranceandGermany,asdid about40percentinthe
United States. The projected costs of caring for the growing numbers of people with dementia are
daunting. The 2010 World Alzheimer Report by Alzheimer’s Disease International estimates that the total
worldwide cost of dementia exceeded US$600 billionin2010,includinginformalcareprovided byfamily
and others, social care provided by community care professionals, and direct costs of medical care. Family
members often playa key caregivingrole,especiallyin theinitialstages of whatis typicallyaslowdecline.
Ten years ago, U.S. researchers estimated that the annual cost of informal caregiving for dementia in the
United States was US$18 billion.

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Economic Strains and Social Protection
29. It’s estimated the UK ‘s cost of ageing is 4-7% of Gross Domestic Product. In 2011,
Northern Ireland spent £687million to support elderly. There is 324 care homes, 6 hospices, 2
private hospitals, and five Health and Social Care Trusts that elderly use. Residential (£79.7 m)
and nursing facilities (£171.2 m) is the most expensive formal care provision for elderly
(excluding hospital care). Population ageing has significant social and economic implications at
the individual, family, and societal levels. It also has important consequences and opportunities
for a country’s development. Although the percentage of older persons is currently much higher
in developed countries, the pace of population ageing is much more rapid in developing
countries and their transition from a young to an old age structure will occur over a shorter
period.
30. Not only do developing countries have less time to adjust to a growing population of
older persons, they are at much lower levels of economic development and will experience
greater challenges in meeting the needs of the increasing numbers of older people. Financial
security is one of the major concerns as people age. It is an issue for both older persons and a
growing challenge for families and societies. Population ageing is raising concerns about the
ability of countries to provide adequate social protection and social security for the growing
numbers of older persons. In many countries, the expectation is that the family will take care of
its economically dependent older members. While some families support their older relatives,
others are not in a financial position to do so in a way that does not affect their own economic
situation. Older persons who do not have family to support them are especially vulnerable.
Informal support systems for older persons are increasingly coming under stress, as a
consequence, among others, of lower fertility, out-migration of the young, and women working
outside the home. There is an increasing consensus that countries must develop social protection
systems that cover at least the basic needs of all older persons. Ensuring a secure income in old
age is seen as a major challenge for governments facing fiscal problems and competing
priorities. Some countries are increasingly worried whether they will be able to pay for pensions
and whether they will ultimately be able to prevent a rise of poverty in old age, particularly in
countries where the majority of older persons are employed in the informal sector. While many
developed countries and some emerging economies are challenged with an ageing workforce and
ensuring the sustainability of pension systems, most developing countries have to establish their
systems now when the challenge is less acute and when the fiscal space available for social
policies is increasing as a consequence of the “demographic dividend”.
Social, Political and Health System Reform
31. Poor conditions earlier in life place older people at risk of serious health problems and
adversely affect their health and vitality. The understanding that the living environment, working
conditions, nutrition and lifestyle choices in younger years influence our health in older age
should be a key ingredient for policies and programmes with an intergenerational focus. As
populations age, it is critical that health systems and the training of health professionals at all
levels are adjusted to meet the requirements of older people, and that ageing is recognized within
diagnostic, curative and rehabilitative care programmes within the formal health system,
especially at primary and community level. Ensuring enabling and supportive environments as

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people grow older is a significant challenge, so that older persons can age actively and
participate in the political, social, economic and cultural life of society. This means that living
arrangements, including housing and transportation are age-friendly, to ensure older persons can
“age in place” and remain independent for as long as possible.
32. Older persons who find themselves in conflict situations, natural disasters – including
those resulting from climate change – and other humanitarian emergencies, are particularly
vulnerable. When younger generations migrate to cities or abroad, older persons are often left
behind without traditional family support. Older people are often the victims of neglect, violence
and abuse because of increasing dependence. Along with these economic changes, the social
context in which older individuals and families function is also changing, affecting, among other
things, the nature of certain types of social relationships and institutions that provide part of the
support infrastructure available to older persons.
Social Changes
33. Demographic and social trends—such as changes in marriage and fertility preferences,
the increasing fragility of unions, the decline of the intact nuclear family, the increasing amount
of time for some young people to transition to adulthood, and the continuing improvements in
health and disability at older ages—all influence the needs of older persons. To deal effectively
with the challenges created by population aging, it is vital to first understand these demographic,
economic, and social changes and, to the extent possible, their causes, consequences, and
implications. Sociology offers a knowledge base, a number of useful analytic approaches and
tools, and unique theoretical perspectives that can be important aids to this task. Furthermore,
sociology is at its heart an integrative science, and it has been suggested that sociology is suited
for “integrating what is known about human behavior” (Gove, 1995, p. 1,197). It concerns itself
with how social systems work and how various social institutions are interconnected, with how
micro and macro social processes are linked, with how attitudes and values are formed, with how
they differ between individuals and groups, and with how realities are socially constructed.

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Figure: Changing social processes and social context in an aging society—The conceptual
model: how the social sciences see the world.
Social Isolation
34. Social isolation, a state studied by sociologists, is a surprisingly unhealthy state. In fact,
the health risks associated with social isolation have been compared in magnitude to the well-
known dangers of smoking cigarettes and obesity (House, 2001). There are a number of
indicators of social isolation, including living alone, having a small social network, infrequent
participation in social activities, that may be associated with health risks (Cornwell and Waite,
2009). Much the same effects are experienced when there is perceived isolation, associated with
feelings of loneliness and perceived lack of social support that are usually st udied by
psychologists. Indeed, loneliness is seenas a prevalent and serious social and public health
problem (Hawkley and Cacioppo, 2010). Research on loneliness, conducted mostly in Western
countries, has shown that at any given time, 20 to 40 percent of older adults report feeling lonely
(De Jong and Van Tilburg, 1999; Savikko et al., 2005; Theeke, 2009; Walker, 1993) and from 5
to 7 percent report feeling intense or persistent loneliness (Steffick, 2000; Victor et al., 2005).
However, while socially isolated individuals tend to feel lonely, loneliness is not synonymous
with objective isolation. Loneliness can be thought of as perceived isolation and is more
accurately defined as the distressing feeling that accompanies discrepancies between one’s
desired and actual social relationships (Pinquart and Sorensen, 2003).
Socioeconomic Status (SES)
35. SES can be measured in multiple ways (e.g., education, income, occupation, wealth,
material deprivation, subjective social status, income inequality) and is one of the most robust
predictors of health and well-being. It is also itself a measure of achievement, and its causes and
consequences constitute one of the central topics of theory and research in sociology. SES is a
frequently used predictor in social demography and social epidemiology (see Gruenewald,
Chapter 10; Shanahan, Chapter 12), as those of high SES have an array of resources with which
to pursue all goals, including health. These resources consist, of course, of financial resources,
but also, in part, of information, social contacts, generally salubrious local environments free of
toxins, access to health care, and skills in evaluating and adopting new treatments and
technologies. Those with low status are more often exposed to stress, have few resources to
counter stress, lack access to health care or face care of poor quality, tend to have poorer health
habits, and face exposure to environmental toxins (Miech et al., 2011). One key dimension of
SES—education—leads to desirable outcomes because it provides training in the acquisition,
evaluation, and use of information, and because it helps develop self-direction and self-efficacy
(Mirowsky and Ross, 2003; Ross and Mirowsky, 2001). SES has been consistently linked to
health outcomes across the life course, regardless of how it is measured and regardless of the
measure of health used (Bruce et al., 2010; Phelan et al., 2004; Smith, 2007).
Multi-morbidity
36. As there are so many age-related diseases, it is not surprising that older people often
develop more than one health problem, a condition known as multi-morbidity. Multi-morbidity is

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usually defined as the co-existence of two or more long-term conditions in an individual. Multi-
morbidity is a common problem in aged populations and has a wide range of individual and
societal consequences. Throughout life, diseases can accumulate in different organs of the body,
resulting in more than one disease existing at once. This is often referred to as multi-morbidity.
Multi-morbidity, often with common underlying pathological symptoms, is associated with
worsening functioning and quality of life.
Frailty
37. Frailty is a clinical syndrome that muscle weakness, bone fragility, very low body mass
index, susceptibility to falling, vulnerability to trauma, vulnerability to infection, high risk for
delirium, blood pressure instability, and severely diminished physical capabilities. Frailty
connotes vulnerability to adverse outcomes and limited ability to respond to and recover from
stressors. Frail older adults are at increased risk of mortality. Frailty and disability are associated
but not synonymous. Behavioral and social risk factors are important in the development of
frailty (Fried et al., 2004; Walston et al., 2006). Not every old person has multi-morbidity. The
gradual decline in cell function may not be severe enough to cause disease, but over time can lead to a
general impairment in function and reduced resilience to environmental hazards such as infections. Where
this impairment particularly affects energy metabolism, bones and muscles, it may be called “frailty”.
38. Frailty was considered an important aspect of ageing. It is not well understood and
therefore difficult to define. The experts believed that current thinking fails to capture the
biological and clinical meanings of frailty. There is sufficiently robust evidence that exercise
helps to tackle the onset of frailty and that frailty may be linked to a weak immune system. For
example, it is known that age-related frailty is associated with a marked reduction in the ability
to fight infection and combat environmental stressors such as the cold.
Interventions to delay the ageing process
39. The evidence on the likely impact of these anti-ageing interventions varies, and there was
no overall agreement on which is the most likely to have a substantial impact on extending the
human lifespan in the future.
Pharmacological drugs
40. Many of the potential interventions discussed were pharmacological drugs, yet there was
scepticism of the pharmaceutical industry’s interest in developing a drug to delay ageing, and the
likelihood of being able to do so, especially in the short-term. Despite this, a number of drugs
were discussed as potential methods of slowing the rate of ageing, with varying degrees of
enthusiasm or scepticism. Some were still in the early stages of clinical research, and may never
get to the point of being licensed for human use. However, others are already licensed and being
used as treatments for specific diseases or as nutritional supplements, but considered to have
additional anti-ageing properties. These established drugs have the most potential to change
lifespan in the short term, as they have already been through the lengthy approval process by the
organisations that regulate the pharmaceutical markets.

21. 21
Drugs already being used
41. Existing drugs already in use that are considered to have the potential to delay ageing are
a somewhat mixed group. This includes statins, which are widely-used drugs to prevent heart
attacks and strokes in people with high cholesterol; rapamycin, which is used to prevent the
immune system rejecting transplanted organs and to prevent blood clots forming in the arteries of
the heart; resveratrol, which comes from red wine and is sold in dietary supplements; and
DHEA, a precursor of the sex hormones testosterone and oestrogen. These drugs have one thing
in common – they have a mechanism of action that relates to one or more steps in the ageing
process.
Rapamycin
42. Rapamycin, also called sirolimus, is used in medicine in several ways: as a drug taken by
mouth that stops the immune system from rejecting transplanted organs; as a treatment for
cancer; and as a coating on the inside of tubes (called stents) that are used to hold open the
arteries of the heart that are narrowed enough to cause a heart attack. Rapamycin binds to part of
the m-TOR molecule and stops cells from dividing. This stops the immune system working
properly, hence its use as an anti-rejection drug. However, this also means that it commonly
causes unpleasant side effects that can lead to diseases or even death.
43. Reports also show that rapamycin reduces brain inflammation associated with
Alzheimer’s disease. Any drug that can potentially treat Alzheimer’s is of great interest to
scientists and so some experts were particularly enthusiastic about the potential of rapamycin as
a means of slowing down the rate of ageing in this area. Unfortunately, rapamycin can have
serious side effects, depending on the doses used and duration of treatment. In animal studies, it
has substantially reduced fertility as well as prolonging lifespan. It also has many side effects
when used as a medicine in humans. At least one in ten people who take the drug regularly
experience urinary tract infections, anaemia and other disorders of the blood that can cause
bleeding, high cholesterol or glucose, headache, abdominal and joint pain, nausea, diarrhoea or
constipation, acne, high blood pressure, swelling of the ankles, or fever. Less frequent side
effects, which affect more than one in a hundred people, include pneumonia, kidney infections,
skin cancer, diabetes, blood clots in the legs, fluid on the lung or in the abdomen, skin rashes and
cysts on the ovary.
44. A distinction needs to be made between the use of rapamycin as a drug to treat specific,
existing and potentially life threatening diseases, where the balance between benefit and harms
may weigh in favour of its use - and its prophylactic use to reduce the rate of ageing in well
people, where the same calculus is unlikely to weigh in its favour. Rapamycin could only ever be
contemplated as an anti-ageing intervention in a modified form that had fewer side effects, and
there is a second generation of ‘rapalogues’ already under investigation. It might be difficult to
produce compounds with the required safety profile since the target of the drug is present in
many cell types, not to mention the difficulty and cost of bringing a new compound to market.
Resveratrol
45. Resveratrol is a natural antioxidant that is found in certain foods such as red wine and
peanuts. It is also available as a food supplement. It has been speculated that taking resveratrol

22. 22
supplements might have the same effect as calorie restriction, but without the need to cut back on
what you eat. It has been suggested as an explanation for the ‘French paradox’ where the harmful
effects of a rich diet are reduced when it is consumed with moderate amounts of red wine.
Resveratrol prevents the triggering of inflammation by mitogen-activated protein kinase. The
activity of one MAPK (p38 MAPK) is particularly important in the ageing process and so
resveratrol might prevent the inflammation caused by senescent cells. Like calorie restriction, it
is also thought to block the m-TOR pathway that controls the body’s response to an increased
supply of nutrients and may affect the action of proteins called sirtuins, which help to regulate
cell division, senescence and inflammation. Resveratrol has been widely researched as a drug
that may slow down the rate of ageing, but there was some scepticism about its potential as an
anti-ageing treatment in humans, exacerbated by one instance of research fraud from a team who
admitted falsifying results from experiments on the drug.
Statins
46. Statins are a group of drugs that are widely used to lower cholesterol levels and prevent
heart disease. In addition to their effect on cholesterol, statins are now known to have an anti-
inflammatory effect, and reduce mortality independently of their impact on cholesterol. They
have therefore been suggested as another type of anti-ageing intervention. They typically reduce
the risk of dying of a heart attack or stroke by around 30%, and also reduce the risk of
developing other long-term diseases associated with a poor blood supply, such as heart failure.
The advantage of statins is that they have been used in humans for many years, are now
relatively cheap and, although there is some dispute about their side effects, are also relatively
safe. Statins are a key component of a number of different “polypills” – tablets that contain
several drugs that are known to be effective at reducing the risks of heart disease and stroke.
Polypills make it simpler to take multiple treatments, and people are more likely to continue to
take a simple treatment rather than one that requires them to remember to take lots of tablets
each day.
DHEA
47. Dehydroepiandrosterone (DHEA or prasterone) is a steroid hormone that is promoted as a
food supplement and is marketed to improve sex drive and fight ageing. It can be bought over the
counter in the USA, but in the UK it is a class C controlled drug under the Misuse of Drugs Act
2001. This means that it is prescribable by doctors off-license, but possession or supply of it in
the absence of a prescription is a criminal offence that can be punished with a fine or
imprisonment.
48. DHEA is a precusor of hormones including the sex hormones testosterone and oestrogen.
Its production in the body declines with age, with levels typically falling in the elderly to 10 to
20% of those in young adults. It has been suggested that this may be a reason for a loss of
interest in sex and erection difficulties in older men – the so-called “andropause”, or male
menopause. Taking these supplements may also improve sex drive in women, and may alleviate
some of the symptoms of the menopause. However, there is no convincing evidence that DHEA
increases strength or slows the rate of ageing in men or women. Some of the experts we spoke

23. 23
with think DHEA might have an important role in helping older adults fight infection and
increase resilience to adverse events such as fracturing a hip or being bereaved.
Drugs in development
P38 MAPK inhibitors
49. The ageing process is associated with the activity of p38 MAPK. A number of inhibitors
of p38 MAPKs are being investigated in human and animal research, in particular as treatments
for cancer, although the experts commented that the pharmaceutical manufacturers might have
shelved these drugs as they were not successful in the original studies. Encouraging the
manufacturers to expand the research into assessing their possible role as ageing-delaying
treatments was considered to be challenging, but promising if it could be done. A wide range of
“anti-ageing” cosmetic products and dietary supplements are available commercially, and are
widely advertised as having antioxidant properties and being able to reduce the signs of ageing.
The experts were sceptical about the possible benefits of these commercial products, and did not
believe any were likely to be effective as anti-ageing interventions.
Behaviour change
50. As we have seen in the previous section, experts are not always in agreement about the
potential for any medicinal drug to have an impact on ageing, and there are few, if any, products
in development or already being prescribed that will have a substantial additional effect on
lifespan in the next decade or so. In contrast, there was general agreement that behaviour or
lifestyle change can be effective at slowing ageing and increasing lifespan. The added advantage
of behaviour change is that it can start from early life and therefore can prevent the development
of diseases in the population at large, unlike medical interventions that tend to be used to treat or
reduce the risk of disease in individuals. Even if simple and safe medicines were available that
could slow down the rate of ageing significantly, we know that adherence to even simple and
straightforward medication regimes is poor, and there may be resistance to “blanket” prescribing
to an entire population because of fears of side effects and that this turns healthy adults into
patients (the so-called medicalisation of normality).
Exercise and physical activity
51. The beneficial effects of exercise and physical activity have been known for many years.
It has been promoted as a way of reducing the risk of many diseases including arthritis, cancer,
diabetes, heart disease, and general frailty, all of which are more common in older people.
However, as with many behaviour interventions, knowing that they are beneficial does not mean
that people will necessarily adopt them. Similarly, poor or inappropriate intervention designs
may mean that behaviour change is not sustained in the longer-term.
52. Hippocrates noticed 2,500 years ago that walking was good for our health, and a
multitude of research since then has reinforced the knowledge that exercise reduces a range of
diseases and can increase lifespan. Exercise does not have to be extreme to be beneficial, and

24. 24
“non-exercise physical activity”, such as doing housework or having an active job, can also
improve health and survival compared with sitting down all day. Burning an extra 1,000 to 2,000
calories a week may be enough to reduce mortality by 20 to 30%. Current advice is to spend up
to 30 minutes on brisk exercise on most days of the week, such as walking at a speed of 3 to 4
miles per hour.
Diet and nutrition
53. There is good evidence that diet and nutrition are central to health and well-being. What
we eat as well as how much we eat influences health in later life. Lower incidence of age related
diseases has been associated with certain dietary lifestyles (for example, a Mediterranean style
diet). Obesity has been linked to both shortening lifespan and to increasing the risk of diseases
such as diabetes, heart disease, high blood pressure and some cancers. The increasing prevalence
of obesity in Western countries over the last decade has been blamed for worsening life
expectancy in some populations. At the other end of the spectrum, calorie restriction has been
shown to increase lifespan in a number of animals, including humans. In the middle of these
extremes, a healthy diet, especially if started in early childhood, is agreed as being important for
a long and healthy life.
Calorie restriction
54. Many experiments have enforced a very low calorie diet on animals in captivity, with
somewhat contradictory results on lifespan. Some studies found that restricting the number of
calories eaten each day could increase lifespan by half as long again, while others failed to show
a difference. Severe calorie restriction also caused a decrease in fertility, especially in females, and very
extreme restrictions, such as in times of famine, clearly are not good for survival. Expert opinion on the
potential for calorie restriction to prolong life was varied, with little active support for it as an
effective anti-ageing intervention. There was acceptance that the evidence is still far from clear
either way.
55. Even if there were benefits from calorie restriction, there are substantial risks of harm
from adopting such an extreme diet in those already old and frail who are at greater risk of
disease and complications such as fractures from weakened bones. It was also acknowledged that
conducting high-quality research in humans is near impossible, for ethical and practical reasons.
And, as with exercise, there are almost insurmountable barriers to persuading the general
population to adopt such a lifestyle change, even if compelling evidence were to emerge that it
would substantially increase lifespans.
Regenerative medicine
56. According to the U.S. National Institutes of Health, regenerative medicine is defined as
the process of creating living, functional tissues to repair or replace tissue or organ function lost
due to age, disease, damage or congenital defects. A common approach in regenerative medicine
is to use stem cells. These are cells that have the potential to develop into many different cell

25. 25
types in the body during early life and growth. When a stem cell divides the two daughter cells
can either remain a stem cell or develop into another type of cell with a different, more
specialized function.
Stem cell therapy
57. Stem cell therapy may use specialised adult cells that have been genetically
reprogrammed or “induced” in the laboratory to revert back to behaving like stem cells (called
“induced pluripotent stem cells”), the patient’s own adult stem cells such as those from bone
marrow, or cells developed from an embryo (embryonic stem cells). Stem cells have unique
regenerative abilities and have the potential to treat diseases such as diabetes, stroke and heart
disease by replacing the damaged cells in the pancreas, brain or heart. However, studies on stem
cell science raise scientific questions as fast as they generate new discoveries.
58. Bone marrow transplantation is a form of stem cell therapy that has been used in the
treatment of leukaemia for over fifty years. It involves the ablation of a sufferer’s bone marrow
using radiation and/or chemotherapy, eradicating all potentially diseased blood cells and
precursors. Healthy bone marrow from a donor with normal stem cells is then implanted in the
patient to repopulate the bone marrow with disease-free white cell precursors.
59. Regenerative medicine is also being used to build artificial organs or joints in the
laboratory, to replace the need for donor organs, which are in short supply. Timelines for the
impact of this research are expected to vary for different organs; complex organs such as the
heart may take a few decades, but organs like a trachea have already been grown from stem cells
and been transplanted. One expert hoped that creating an artificial but living heart for a patient
would only take another 20 years to achieve.
Gene therapies and epigenetics
60. An area of research into anti-ageing interventions discussed by the experts is those studies
that aim to change the genetic make-up of an individual in some way. Some diseases are caused
by faulty genes, and techniques to replace these with normal genes could, if successful, provide a
cure. In other situations, the problem might be more that a normal gene is not working because it
has been “turned off”. The study of how our genes are controlled and ways in which this might
be manipulated to reduce ageing and disease is called “epigenetics”.
61. Gene therapy is an area where the experts thought there was potential for benefit.
Inserting genes into a person’s cells to treat or prevent disease is an exciting new area of
medicine and one that has shown limited success so far in treating some types of cancer and
inherited disorders. Although there is much hope for gene therapy, the technique is still largely
experimental. Epigenetic therapy is the process of artificially turning genes on or off, or
changing the way in which genes are controlled. It is a process that can occur in nature: the

26. 26
development of cancer may involve a mutation in the DNA that turns off the genes that control
cell division, for example.
Myths Affecting Health Promotion in Older Age
62. In every society, many myths prevail about older adults and the aging process. Older
adults are assumed to be sick, demented, frail, weak, disabled, powerless, sexless, passive,
isolated, discontented, and incapable of learning (Rowe & Kahn, 1998). Ageism is fueled by
societal messages delivered by the media. To change society’s views of aging, the public must
unlearn some deeply rooted misconceptions about older individuals. The ability of older people
to contribute actively to society depends on their well-being and quality of life. The majority of
them lead active, fulfilling lives because of their good health status. To ensure that policy makers
and the society continue to promote active aging, it is important to eliminate common myths
about aging that can create barriers to the promotion of health (WHO, 1999).
Myth No. 1. The Majority of Older Adults Live in Developed Countries
63. The reality is that more than 60% of older people live in developing countries. Of an
estimated 580 million older adults in the world, roughly 355 million live in developing countries
(WHO, 1999).
Myth No. 2. All Older People Are Similar
64. As a population, people aged 65 and older are not a homogeneous group. Their diversity
is based on such factors as gender, ethnic or cultural background, composition of family and
community, country of origin, type of living arrangements and environment, levels of education
and income, degree of involvement and activity, level of skills, and types of social roles. All
these factors affect an individual’s life experience and have a strong influence on his or her aging
process (WHO, 1999).
Myth No. 3. The Aging Process Is the Same for Men and Women
65. As a result of differences in gender roles and responsibilities, life expectancy, and
biological characteristics, the aging process is different for men and women. An examination of
mortality and morbidity in the later years reveals that older women live longer than their male
counterparts, experience different chronic conditions, and are at higher risk for functional
limitations (WHO, 1999). In addition, they tend to report a greater need for help with personal
care and the activities of daily living than older men do.
66. Because women make up the majority of the aging population (Robinson, 2007), one
particular area of concern to society is the ability to meet women’s increasing requirements for
health care and long-term care as they age. As a result of their longer life expectancy, they are
more likely than their male counterparts to be widowed and to lack a significant other who can
be their primary caregiver (WHO, 1999). Therefore, more women are dependent on formal care
services provided either in the home or in long-term health care facilities.

27. 27
67. Men are generally at higher risk than women are for heart disease and stroke, although
the higher prevalence of these diseases among men should not negate the fact that women also
are at risk (WHO, 2002) for these and other illnesses, such as cancer, chronic lower respiratory
diseases, and Alzheimer’s disease. Another common illness among older women is osteoporosis,
the signs and symptoms of which are not visible, thus making the disease a silent threat for
increased disability and decreased quality of life (Robinson, 2007).
Myth No. 4. Older People Are Frail
68. Throughout the 20th century, the patterns of illness in the aging population have changed
dramatically. Historically, acute infectious diseases were the most prevalent causes of death.
Today, however, chronic illnesses that can be managed over time are seen more frequently in the
older population (Rowe & Kahn, 1998). This shift in the nature of older individuals’ health needs
has led to changes in the degree of disability caused by chronic illnesses. Manton, Gu, and Lamb
(2006) reported a significant decrease in the occurrence of chronic disability among older adults
between 1982 and 2005. In 1982, 73.5% of people aged 65 years and older identified themselves
as nondisabled, whereas 81% did so in 2005. According to Manton and coauthors, major long-
term improvements in the ratio of activity level to total life expectancy are projected for people
aged 85 and older. If current trends persist, the number of severely disabled individuals should
decline 50% by the year 2050 (WHO, 1999).
69. According to the WHO (2002), in 2001 roughly 20% of older adults worldwide received
formal care services. Approximately two thirds of those services were home based and included,
but were not limited to, visiting nurses and home-delivered meals. To maintain older adults’
independence and promote their well-being, rehabilitative services, physical environments
adapted to their needs, and education regarding healthy lifestyles must be available to them. It is
virtually never too late to adopt healthy behaviors, such as smoking cessation, proper diet, and
physical activity that can improve a person’s quality of life (Rowe & Kahn, 1998).
Myth No. 5. Older People Do Not Contribute to Society
70. Valuing older people for their ongoing roles and participation in their families,
communities, and economies is important. Like everyone else, the less older people are
challenged, the less they can achieve. The elimination of age discrimination will require an
emphasis on programming that is flexible and offers lifelong opportunities for learning.
Therefore, educational facilities and institutions should adjust their curriculum to accommodate
differences between older and younger people regarding the pace at which they learn and their
ability to retain information (Rowe & Kahn, 1998).
71. Longitudinal studies focusing on promotion of health have highlighted how healthy
behaviors have a direct impact on the length and quality of a person’s life. In the context of the
myth that older adults do not contribute to society, deriving a constant sense of purpose or
involvement by participating in society is a crucial and central aim of successful aging. The
Administration on Aging (2008) points out that older adults are actively engaged in their
communities both formally and informally by providing millions of hours of volunteer,
community, and civic service. They not only contribute their spare time, but impart knowledge

28. 28
of culture, values, and life experiences to younger generations as well. As older adults live
longer, healthier lives, they will be able to continue contributing their valuable knowledge to
society. Regular activity, along with a stable support system and confidence in their ability to
handle what life has to offer, helps them to maintain good health (Rowe & Kahn, 1998).
72. Older members of communities are not only invested in their own network of family and
friends; they also are interested in and care about the greater community. For example, Senior
Corps (Research Triangle Institute [RTI] International, 2003)—a program developed by the
Corporation for National and Community Service—has connected roughly 500,000 senior
volunteers 55 years and older with opportunities for meaningful unpaid work. The organization’s
offerings include the Retired Senior Volunteer Program (or RSVP), the Foster Grandparent
Program, and the Senior Companion program (RTI International, 2003). Participants in these
programs have devoted more than 1 billion hours to communities nationwide.
73. Another volunteer program, Seniors for Schools, shares their leadership and
organizational skills with the greater community. The program’s mission is to provide literacy
services to children in primary schools across the United States (Project STAR, 2001). In 2000,
486 volunteers served 5,462 students. Programs such as these demonstrate the willingness and
ability of older individuals to engage with people of all ages in their communities. As their
quality of life and life expectancy increase, the number of programs available to the rapidly
increasing population of older people will increase rapidly as well.
Healthy and active ageing
74. It is one of the most important demographic megatrends with implications for all aspects
of our societies. Ageing is already having a far-reaching impact on living arrangements and the
way that societies and economies work. The process of change towards more aged societies is
inevitable. Ageing is happening in different regions and in countries at various levels of
development. It is proceeding at a faster pace in developing countries, where social protection
systems are weak and institutional development is still work in progress. Ageing is a triumph of
development. People can now live longer because of improved nutrition, sanitation, medical
advances, health care, education and economic well-being. Being able to lead fulfilled and active
lives in our later years has benefits not only for individuals but for society as a whole. But as the
number and proportion of older persons are growing faster than any other age group, and in an
increasing range of countries, there are concerns regarding the capacities of societies to address
the challenges associated with these demographic shifts. Projects presented in the compendium
therefore address a wide range of issues, that can, when taken together as a comprehensive multi
stakeholder strategy improve the health of older people. These range from:
a. Encouraging and improving the employability of older people, by e.g. improving
workplace health and providing more flexible working conditions and retirement options;

29. 29
b. Providing older people with opportunities to share and develop their knowledge
and skills and remain socially engaged and valued through counseling and voluntary
activities;
c. Providing opportunities for life-long-learning, such as courses to develop IT
skills, and cultural activities such as festivals and singing or music groups;
d. Developing and mainstreaming services (e.g. transport, housing, health) that are
sensitive to the needs of older people and encouraging and empowering them to become
more politically active in e.g. city councils;
e. Addressing isolation through home visits and the organisation of specific
activities in remote areas and through the provision of accessible services;
f. Developing health, social and educational services that are sensitive to
individual capacities, culture and circumstances (e.g. older migrants);
g. Developing health promotion activities (e.g. physical fitness courses) that are
specifically designed for the needs of this target group, and ensuring that they are easily
accessible in terms of proximity, cost, language, etc;
h. Providing support and advice to ‘carers’ of much older or disabled family
members.
i. As citizens of an aging world it is necessary for the world’s societies to
acknowledge older persons as a valuable resource and to combat ageism by collectively
facilitating opportunities to involve older adults actively in this process. To achieve this
goal, health care services not only must be available but also must include health
promotion and encourage intergenerational solidarity.
j. Because health and level of activity in the later years are primarily determined by
one’s life course of experiences, exposures, and actions, one’s choices for active living
should begin early in life. Participating in family and community life, eating well-
balanced meals, being physically active, and avoiding unhealthy behaviors can promote
more successful aging.
k. Participation of older adults in daily activities can range from volunteer or paid
work to physical fitness activities to meaningful hobbies. Roughly 2 million children in
the United States are cared for by their grandparents, and an estimated 1.2 million of
these children live with their grandparents (WHO, 1999). This means that the grand
parents provide the care that parents would provide because they aren’t available. Some
grandparents regularly perform parenting responsibilities for their grandchildren. All
individuals age within the context of their surroundings which include family, friends,
and community. The ability of older people to partake of and enjoy life depends on the

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risks and opportunities available to them throughout their lives and on the support
network that surrounds them (WHO, 2002).
l. The trend in care services for older adults has been shifting from residential and
housing services that focus on maintenance to community-based services that emphasize
treatment and rehabilitation (Robinson, 2007). Today, the focus on illness is how it
affects a person’s ability to function within the community. As Robinson pointed out,
many older adults can function at a high level. For example, they can be providers as well
as recipients of care (WHO, 1999).
International Responses on Ageing
75. The Second World Assembly on Ageing, held in Madrid, Spain in 2002 produced a bold,
rights-based and policy relevant Political Declaration and Plan of Action on Ageing to manage
the challenges of population ageing in the 21st century. Both were adopted later in the same year
by consensus by the General Assembly of the United Nations. The Political Declaration and Plan
of Action address major issues that are most pertinent to the well-being of older people around
the globe and suggest concrete policy actions in the three priority areas of older persons and
development, advancing health and well-being into old age, and ensuring enabling and
supportive environments.
76. The Madrid Plan was preceded by two international documents on ageing: the Vienna
International Plan of Action on Ageing and the United Nations Principles for Older Persons. The
first international instrument on ageing, the Vienna Plan, was adopted by the first World
Assembly on Ageing in 1982, convened in recognition of “the need to call worldwide attention
to the serious problems besetting a growing portion of the populations of the world”. The focus
of the Vienna Plan was on developed countries where the implications of population ageing were
already recognized and well established. In 1991, the United Nations General Assembly adopted
the United Nations Principles for Older Persons and encouraged governments to incorporate
them into their national programmes whenever possible. The 18 United Nations Principles,
which seek to ensure that priority attention will be given to the situation of older persons, address
the following five areas: independence, participation, care, self-fulfilment and dignity of
older persons. These two documents were reaffirmed at the Second World Assembly on Ageing
at which governments also recognized that population ageing is increasingly an issue in
developing countries.
77. By adopting the Madrid Plan, governments agreed for the first time on the need to link
ageing with human rights. This happened at a time when the human rights approach to
development was gaining increasing importance on the international stage as, for example,
during the International Conference on Population and Development held in Cairo in 1994 and
the Fourth World Conference on Women held in Beijing in 1995. The Political Declaration
affirms the commitment to the promotion and protection of all human rights and fundamental
freedoms, including the right to development. There is a shift away from viewing older persons
as welfare beneficiaries to active participants in the development process, whose rights must be
respected, protected and guaranteed.

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78. The Madrid Plan includes a specific recommendation to include older persons to be “full
participants in the development process and also share in its benefits”.23 The Plan covers 18
areas of concern to older people and makes 239 recommendations for action. Its overall objective
is to enable a “society for all ages” with a broad aim “to ensure that people everywhere are able
to age with security and dignity and to continue to participate in their societies as citizens with
full rights”. The Madrid Plan, like the Millennium Declaration, recommends to “reduce the
proportion of persons living in extreme poverty by one half by 2015”.25 Nevertheless, the
Millennium Development Goals (MDGs) in their current form do not explicitly respond to the
issues of ageing populations. A review of MDG reports since 2005 undertaken by the United
Nations Development Programme (UNDP), revealed no mention of the situation of older people
or any intervention geared towards them. The Madrid Plan, however, acknowledges that older
persons have an important part to play in the achievement of the MDGs and should benefit from
interventions designed to achieve them. The Madrid Plan also calls for the integration of a
gender perspective into all policies, programmes and legislation and recognizes the differential
impact of ageing on women and men. The Madrid Plan emphasizes the relationship between
gender and ageing, positioning older women as both agents and beneficiaries of socioeconomic
progress. Following the recommendations of the Madrid Plan supports older women’s
empowerment, for example, through adult literacy programmes, self-help groups, access to credit
and help with accessing entitlements.
How to promote active Ageing

32. 32
79. Active aging is a term used to describe the maintenance of positive subjective well-
being, good physical, social and mental health and continued involvement in one’s family, peer
group and community throughout the aging process. It is defined by the World Health
Organization (WHO) as “the process of optimizing opportunities for health, participation and
security in order to enhance quality of life as people age.” Active engagement is being involved
in the social, economic, spiritual, cultural and/or civic life of the community. Most older people
are actively engaged in the community. Following are the components of active ageing:

33. 33
a. People: Trained and committed individuals are needed to meet the needs,
capabilities, expectations, dreams and desires of older adults.
b. Perceptions: Ageism and negative stereotypes of aging impede an inclusive
society.
c. Potential: Population aging is creating new economies. With population aging,
age 50-plus consumers will dominate purchasing decisions for decades to come, creating
untold business opportunities for those who attract them. What will these opportunities
be, and how will businesses tap them?
d. Products: Products and services are needed that tailor to older adult needs and
expectations. Many providers today continue to focus their products and services towards
youth. Research shows this lack of interest in the older consumer stems from ageism and
a limited understanding of this market. By designing more inclusive products and
services, organizations will benefit from the vast spending power of the age 50-plus
market.
e. Promotions: Older adults are a key market to attract. A great majority of
marketers have neglected older consumers, despite the fact that within five years, the 50-
plus market will account for 70% of all disposable income. Effective promotions and
marketing must be rooted in the realities of life for older adults. Shifting today’s
marketing model will not only meet consumer demand, but also inspire societal change.
f. Places: Environments must be constructed to enable multiple functional abilities.
Environments can encourage or discourage people of all ages in leading active, engaged
lives. From indoors to outdoors, what environments will be needed to support active
aging?
g. Policies: The human rights of older adults should be protected. Consider how
policies can support inclusiveness. Specific global, national and corporate policies will be
needed, however, to guarantee the human rights of older adults. Examples include access
to social security, age discrimination laws, and affordable care and housing. Are your
policies inclusive? Or, will you need to revisit them?
h. Increasing older people's participation in the economy and society. Creating age-
friendly environments, increasing the retirement age and the labour market participation
rate.

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i. Food and Behavioral Lifestyles. Regular physical exercise reduces mortality risk
by about 35% (e.g., Healthy Aging Longitudinal European study). Elders with healthy behavioral
life styles show four times less disability than those who smoke, drink too much, do not exercise,
and are obese. Moreover, in those with good behavioral habits the onset of initial disability was
postponed by 7.75 years. Mediterranean diet (low intake of saturated and trans fat and high
consumption of fruit and vegetable) is stronger related to survival and life expectancy. This type
of diet decreases coronary mortality about 40% and all causes of mortality about 20%.
Cognitive Activity and Training
80. More frequent cognitive activity in everyday life is associated with a reduction of
approximately 19% in annual rate of cognitive decline, and is also a protective factor against
dementia. The effects on cognitive functioning of cognitive training are of a magnitude
equivalent to the decline expected in elders without dementia over a period of 7 to 14 years,
though longer follow-up study is required.
Positive Affect and Coping
81. Positive Affect reduces mortality in older individuals. The benefits of positive affect
can be observed in conditions as diverse as stroke, re-hospitalization for coronary problems, the
common cold, and accidents; highly activated positive emotions were associated with better
functioning of cardiovascular, endocrine, and immune systems. A positive attitude towards life
may help us avoid becoming frail. For those reporting positive affect 7 years earlier, the chance
of becoming frail fell by 3%, while the chances of having better health outcomes, greater
functional independence increased, as did survival rates. The authors conclude from these
finding that positive affect is protective against functional and physical decline in old age as well
as negative affect such anxiety are requiring coping and management. The most important
conclusion emerging from coping and aging literature is that although there is a broad evidence
about the stability of coping behaviour across life span, authors distinguish specific positive
coping skills in old age which can be trained and promoted.
Sense of Control and Self-efficacy.
82. Older adults with a high sense of control are better off on many indicators of health
and well-being and those who have a lower sense of control may be at increased risk for a wide
range of negative behavioral, affective, and functional outcomes, including higher levels of
depression, anxiety, and stress, use of fewer health protective behaviors (e.g., exercise) and
compensatory memory strategies (e.g., internal or external memory aids), and have poorer health
and memory functioning. Also, the sense of control is a powerful psychosocial factor that
influences well-being and it is a good predictor of healthy and active aging; finally, sense of

35. 35
control can be trained as has been largely tested. Among control concepts, self-efficacy is
perhaps the best well-known construct in successful ageing literature.
Social Functioning and Participation
83. The association between social relationships and the prevalence and incidence of and
recovery from disability has been well established [52]. (2) Research results have shown a strong
and robust cross-sectional association between social engagement and disability, more socially
active persons reporting lower levels of disability than their less active counterparts. There is
empirical evidence that social activity and participation improve cognitive functioning.
Flexible careers through education and training
84. For many decades many working careers had a clear distinction between three major
periods: qualification phase, working phase and retirement phase. In response to emerging social
circumstances resulting from population ageing, the concept of active ageing calls for a change
of paradigm of this tripartite approach. As employees today are expected to be more flexible in
terms of duties they perform and working conditions, the commitment to life-long education
constitutes a pre-condition of an active and flexible life style.
Adapting working environments to the needs of all generations
85. A higher retirement age calls for environments which enable older workers to remain
healthy, satisfied and productive, as good health of employees and productivity are correlated.
The responsibility here is not only with policy makers, but also with companies and individuals.
Stakeholders may consider together how to best promote healthy workplaces and how to provide
age-friendly and safe work environments that are adequate for intergenerational cooperation.
Important is also the prevention of distressing interpersonal experiences at the work place, such
as bullying or harassment, which may cause anxiety and frustration, and which can lead to a
variety of illnesses (e.g. the burn-out syndrome) or a premature exit from employment.
Social inclusion
86. A number of studies have shown that socially involved persons are happier and healthier
throughout the life course, while loneliness may be caused by various factors such as the loss of
a partner, reduced social activities, and decreased physical activity.17 Member States can
promote the social integration of older and younger persons by facilitating opportunities for
volunteering and intergenerational exchange. Although it is never too late to become active in
volunteering, there is evidence that people who are active throughout the life course are more
likely to remain active when reaching retirement age.18 State-supported volunteering
programmes may offer opportunities for societal engagement and political participation (e.g. in
senior advisory boards or senior organisations), but should not serve as an opportunity to replace
regular employment.
Active through the participation in social family networks
87. Intergenerational solidarity, although often deriving naturally from kin and non-kin
relationships, may be supported by an appropriate legal framework. There is a particular need for

36. 36
action to enhance opportunities for social integration in the “familialism by default”- pattern, as
here older persons might become dependent on the goodwill of family members, whereas
younger relatives might become overwhelmed with their duties. Life-long education and social
community activities broaden the spectrum of opportunities for social interaction. In the pattern
that incline to defamilialization the exchange of monetary and non-monetary support between
family members may be alleviated in order to create incentives for building stronger family ties.
Preventive health measures
88. A healthy life style throughout the life course: Building the ground for active ageing
starts at a very early age and continues throughout the life course. Thus, preventive measures are
a well spent investment into the health of gradually ageing societies. In the introduction of this
brief it has been outlined that member States may be able to offer incentives and legal
frameworks for healthy life styles, however the ultimate responsibility for choosing such a path
is with the individual. Creating a suitable framework in which people can exercise, reduce stress
or improve their diet may impact the health status of citizens, if the individual can be convinced
to use them. Preventing disease and accidents may also include improving the quality of housing
or safety of transport facilities.
Frailty and long-term care
89. Towards community care : Although an active and healthy lifestyle may contribute to a
longer and fitter life, a status of frailty or disability cannot always be prevented. The concept of
active ageing would be aimed at enhancing well-being by allowing older persons to remain fully
integrated citizens of their community. Member States may want to promote infrastructures for
long-term care services that empower patients to remain active citizens and prevent
institutionalization, such as homecare or daycare services, out-patient health care services, the
provision of medical equipment, but also high quality palliative care services to allow terminally
ill people to die in dignity at home. Sufficient social protection (e.g. pensions and social security
measures) are necessary for older persons to take advantage of these services which contribute to
the ultimate aim to help them remain integrated into their community.
Labour market participation
90. It is desirable for persons to be able to remain in employment as long as they are fit
enough and wish to work. Abolishing mandatory retirement might be seen as an important step
in this regard. Adjustments to statutory pensionable age and/or years of contributions may
provide for smooth and gradual retirement options that leave room for personal choice with the
ultimate aim to allow persons to promote their own well-being and quality of life. On the other
hand, in order to prevent an early exit from labour markets of older employees, who have not yet
reached the retirement age, it is necessary to develop appropriate labour market instruments.
These instruments shall be geared towards the establishment of incentives to stay in the labour
market and the creation of an age-friendly working environment including age-adapted
workplaces. Life-long learning programmes as part of comprehensive education strategies are
beneficial for improving the employability of all generations.

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Conclusion
91. Although population ageing is often portrayed negatively, it is important to recognize that
increased survival to and beyond later life is a great achievement and that the inverse of
population ageing is rapid population growth, which itself poses challenges. Similarly, although
the needs of the young, middle aged and old are sometimes presented as being in conflict, in fact
different generations are linked through shared family lives and of course expectations of the
future – old people were once young and the only alternative to growing old is premature death.
Older generation is the guiding figures for the present younger and the present achievements are founded
on their immense sacrifices that they have made while they were young. So, it is a human and social
responsibility to go on with the older generation and is wise to integrate them into economic activities and
make them economically active participants of the society.
92. This is not a disaster waiting to happen, in fact it is offering us new opportunities to find
new ways to continue to live together and continue to prosper. The core message of this
presentation is that the population ageing can lead to a disaster or it can become an opportunity
but it all depends on how well ageing societies prepare for it. The analyses included here go
through different policy domains and also discuss ideas about how public policies ought to
change in the future. The aging population phenomenon is offering us a new setting in which we
have to realize and benefit from the full potential of older people. A new social coherence will
have to be found in a society in which younger and older people live well and productively with
each other. And this phenomenon is actually not just a challenge for public policies but also for
the private sector and there is even greater need than ever before for all these key stakeholders to
work together for the future.

38. 38
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